Mitigating the Risk of Aberrant Use of Opioids in Patients With Cancer Pain
Authors: Marcin Chwistek
Journal: Journal of the National Comprehensive Cancer Network (2023)

T he burden of cancer pain remains high, and the negative consequences of under- treated cancer pain are far-reaching.Opioids are the gold standard for treating moderate to severe cancer pain and are endorsed by multiple guidelines.Patients with cancer pain receiving chronic opioids are also at risk for aberrant opioid behaviors, perhaps at a higher rate than previously thought. 1 Therefore, oncology and palliative medicine clinicians face the dual responsibility of effectively addressing cancer pain while mitigating the risk of aberrant opioid behaviors. 2o make matters more complex, unintentional consequences of policy changes related to the epidemic of overdoses plaguing the United States and other countries might have exacerbated the problem of undertreatment of cancer pain.In this issue, Moryl et al 3 reported that between 2000 and 2017, their group saw a decline in opioid prescribing for patients near the end of life by almost 40%, while concurrently, emergency department visits increased by .50%.Haider et al 4 reported that between 2010 and 2015, the median morphine equivalent daily dose patients received at the time of referral to their supportive oncology decreased from 78 to 40 mg/d.At the same time, an increase was seen in prescriptions for nonscheduled opioids such as tramadol, suggesting that some oncology clinicians have become less comfortable prescribing opioids for cancer pain. 4his is unsurprising, given that there is a paucity of data, tools, and guidelines to aid clinicians in safe and effective opioid prescribing for cancer pain. 5As a result, clinicians are forced to rely on their subjective assessment of patients, which is primarily based on their previous experience and attitudes toward opioid prescribing.As a result, some refrain from prescribing opioids when it may be appropriate and necessary.At the same time, others ignore potential aberrant behaviors and miss an opportunity to intervene.In a recent study, palliative medicine physicians reported that aberrant opioid use was underdiagnosed, challenging to manage, time-consuming, and stressful. 3,6 recent meta-analysis estimated the prevalence of opioid use disorder (OUD) among patients with cancer-related pain to be 8% and the risk for OUD to be 23.5%. 7This is consistent with another report that determined that at least 1 in 5 patients with cancer are at increased risk for OUD. 8 In another study of 432 patients with advancedstage cancer seen at a supportive care clinic, 18% were identified as using opioids in a way other than prescribed. 9However, it is essential to note the significant heterogeneity of the studies that prevents us from making conclusions about the actual risk of aberrant opioid use. 7,10t is critical to be able to recognize patients at risk for aberrant use of opioids, including substance use disorder (SUD), early and accurately, because there are strategies that help to mitigate the risk.Several factors, such as younger age (,45 years), male gender, a personal or family history of SUD or mental health disorder, and alcohol and tobacco use, have all been associated with the development of SUD.It is essential to highlight, however, that no single factor or a set of factors can reliably predict aberrant opioid behaviors in patients. 1arious screeners, including the Screener and Opioid Assessment for Patients with Pain (SOAPP); the Cut Down, Annoyed, Guilty,